Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Administration

First Advisor

Jan Clement

Second Advisor

Michael McCue

Third Advisor

David Harless

Fourth Advisor

Kate Lapane


California’s elderly population over age 85 is estimated to grow 361% by the year 2050. Many of these elders are frail and highly dependent on caregivers making them more likely to need nursing home care. A 1998 United States Government Accountability Office report identified poor quality of care in California nursing homes. This report spurred multiple Assembly Bills in California designed to increase nursing home nurse staffing, change the state’s Medi-Cal reimbursement methodology, or both. The legislation culminated in Assembly Bill (AB) 1629, signed into law in September 2004, which included the Long-Term Care Reimbursement Act. This legislation changed the state’s Medi-Cal reimbursement from a prospective, flat rate to a prospective, cost-based methodology and was designed in part to increase nursing home nurse staffing. It is estimated that this methodology change moved California from the bottom 10% of Medicaid nursing home reimbursement rates nationwide to the top 25%. This study analyzed the effect of AB 1629 on a panel of 567 free-standing nursing homes that were in continuous operation between the years 2002 – 2007. Resource Dependence Theory was used to construct the conceptual framework. Ordinary least squares (OLS) and first differencing with instrumental variable estimation procedures were used to test five hypotheses concerning Medi-Cal resource dependence, bed size, competition (including assisted living facilities and home health agencies), resource munificence, and slack resources. Both a 15 and 25 mile fixed radius were used as alternative market definitions instead of counties. The OLS results supported that case-mix adjusted licensed vocational nurse (LVN) and total nurse staffing hours per resident day increased overall. Nursing homes with the highest Medi-Cal dependence increased only increased NA staffing more than nursing homes with the lowest Medi-Cal dependence post AB 1629. The fixed effects with instrumental variable estimation procedure provided marginal support that nursing homes with more home health agency competition, in a 15 mile market, had higher LVN staffing. This estimation procedure also supported that nursing homes with more slack resources (post AB 1629) increased nurse aide and total nurse staffing while nursing homes located in markets with a greater percentage of residents over the age of 85 had more nurse aide staffing.


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Is Part Of

VCU University Archives

Is Part Of

VCU Theses and Dissertations

Date of Submission

May 2011